Advancing Dermatology Education and Care in Rwanda: The Impact of a New Academic Partnership.

It is the realization of a long-dreamed aspiration to create a university that would advance global health delivery by training a new generation of global health leaders who are equipped to not just build, but sustain effective and equitable health systems.

Depression and thoughts of self-harm or suicide among gender and sexually diverse people in a regional Australian community.

ISSUES ADDRESSED: There is a paucity of data regarding depression and thoughts of self-harm or suicide among gender and sexually diverse (GSD) people living within Australian regional/rural locations. This study aims to elucidate these issues and fill a critical gap. METHODS: The sample included 91 GSD people from a regional community in South-West Queensland utilising the PHQ-9 to determine presence/severity of depression and self-harm/suicide ideation. These data were drawn from a larger health and wellbeing survey. Raw mean scores were calculated to determine prevalence/severity of clinical symptoms. Bayesian ordinal regression models were employed to analyse between-subgroup differences in depression and self-harm/suicide ideation. RESULTS: Overall, 80.2% of GSD sample experienced depression (35.2% severe, 45.1% mild/moderate) and 41.8% experienced self-harm/suicide ideation in the past two-weeks. Trans and nonbinary people experienced higher levels of depressions than sexually diverse cisgender people. Pansexual and bisexual people experienced higher levels of depression than gay people. Trans people experienced higher prevalence of self-harm/suicide ideation than cisgender and nonbinary people, with no differences between sexuality subgroups. CONCLUSIONS: These findings contribute to deeper and more nuanced insights regarding clinically salient depressive and self-harm/suicide ideation symptoms among trans, nonbinary, bisexual, pansexual and queer people in regional Australian communities, with the aim to ultimately reduce mental health prevalence, improve mental health outcomes and health promotion among GSD people. SO WHAT?: The current findings revealed GSD people experience high prevalence of depression and self-harm/suicide ideation indicating tailored mental health awareness-raising, training and health promotion is warranted to enhance psychological support.

Part II: Cutaneous manifestations of peripheral vascular disease.

In this Part 2 of a 2-part continuing medical education series, we review the epidemiology of peripheral vascular disease, its association with cutaneous symptoms, and the diagnosis and evaluation of cutaneous features of vascular disorders. As peripheral vascular disease becomes more prevalent globally, it is essential for dermatologists to become competent at accurately recognizing and diagnosing cutaneous manifestations and directing individuals to receive appropriate care and treatment.

Part I: Cutaneous manifestations of cardiovascular disease.

In this part 1 of a 2-part continuing medical education series, we review the epidemiology and pathophysiology of cardiovascular disease, its association with cutaneous symptoms, and the diagnosis and evaluation of cutaneous features of cardiovascular syndromes, including infective endocarditis, acute rheumatic fever, Kawasaki disease, cholesterol embolization syndrome, lipid disorders, cardiac amyloidosis, and cardiac myxomas. As the incidence and prevalence of cardiovascular diseases increase, dermatologists play an essential role in recognizing the cutaneous manifestations of cardiovascular diseases in order to appropriately connect patients with follow-up care.

A trans agent of social change in incarceration: A psychobiographical study of Natasha Keating.

OBJECTIVES: This psychobiography focuses on the advocacy work of Natasha Keating, a trans woman incarcerated in two male prisons in Australia between 2000 and 2007. Incarcerated trans women are a vulnerable group who experience high levels of victimization and discrimination. However, Natasha advocated for her rights while incarcerated and this advocacy contributed to substantial changes in the carceral system. This psychobiography uses psychological understandings of resilience as well as the Transgender Resilience Intervention Model (TRIM) to investigate the factors that enabled this advocacy. METHOD: Data consisted of an archive of letters written by Natasha and interviews with individuals who knew her well. This psychobiography was guided by du Plessis' (2017) 12-step approach and included the identification of psychological saliencies and the construction of a Multilayered Chronological Chart. RESULTS: Natasha's life is presented in four chapters, with each chapter including a discussion of resilience based on the TRIM. CONCLUSIONS: The TRIM suggests that during incarceration, Natasha was able to access more group-level resilience factors than at any other time in her life. This, combined with individual resilience factors, enabled her advocacy. This finding has implications for advocacy in general as it highlights the importance of both individual- and group-level factors in enabling individuals to effectively advocate for change in their environments.

Patient-centered Outcomes for Individuals with a Venous Leg Ulcer: A Scoping Review.

GENERAL PURPOSE: To summarize randomized clinical trials addressing patient-centered outcomes of individuals with a venous leg ulcer. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Summarize the results of the review of randomized controlled trials addressing patient-centered outcomes of individuals with a venous leg ulcer.2. Identify the limitations of the research analyzed for the review.

To summarize randomized clinical trials addressing patient-centered outcomes of individuals with a venous leg ulcer with a scoping review. Authors searched PubMed using MESH terms for "venous ulcer" AND "randomized" for randomized clinical trials published from January 2002 to October 2021 that explored content-validated patient-centered outcomes for individuals with a clinically diagnosed venous leg ulcer. Authors also searched Cochrane Reviews from inception to April 15, 2022 for additional references using the same MESH terms. Studies in any setting were included if primary or secondary outcomes were venous ulcer-related mobility, pain or analgesic use, healing, infection, quality of life (including odor, social isolation, depression), amputation, or patient-level costs of treatment. Preclinical or nonrandomized clinical studies or those without venous leg ulcers were excluded. Authors tabulated interventions studied, numbers of patients treated per group, risk of delayed ulcer healing, and statistical significance of comparisons of 485 qualifying articles in Google Sheets. Authors graphically represented and tabulated frequencies of studies addressing patient-centered outcomes of individuals with venous ulcers. Studies mainly reported effects of compression, dressings, topical antimicrobials, or systemic therapy on patient healing or pain outcomes. Related ischemia, ultrasonography, or risk factors for delayed healing were not consistently reported, inflating variability of outcomes and decreasing consistency of differences reported. Research is needed on the mobility, amputation risk, infection risk, quality of life, and healthcare costs of patients with venous ulcers. Promising interventions include grafts, exercise, analgesics, electrical modalities, negative pressure, or vascular interventions. Consistently reporting each patient's baseline ischemia and vascular condition would improve relevance.

Do Commonly Used Antimicrobial Topicals Facilitate Venous Leg Ulcer Healing?

OBJECTIVE: To survey which topical antimicrobials are most helpful in treating venous leg ulcers (VLUs). DATA SOURCES: In this narrative review, the authors searched the databases of Google Scholar, Cochrane Library, and Wiley Online Library. STUDY SELECTION: Studies were eligible for inclusion if they studied the effects of antimicrobial agents on chronic VLU healing and were published after 1985. Exceptions to this were in vitro studies of manuka honey and Dakin solution (Century Pharmaceuticals). Search terms included "venous leg ulcer", "nonhealing ulcer", "antimicrobial resistance", and "biofilms". DATA EXTRACTION: Data extracted included design, setting, descriptions of intervention and control groups, outcomes, data collection tools, and potential harms. DATA SYNTHESIS: A total of 19 articles encompassing 26 studies/trials met the inclusion criteria. Of the 26 studies, 17 were randomized controlled trials; the remaining 9 were a mix of lower-quality case series and comparative, nonrandomized, or retrospective studies. CONCLUSION: Studies suggest that VLUs can be treated with multiple different topical antimicrobials. Depending on the extent of chronicity and bacterial colonization, some antimicrobials may be better suited than others.

Navigating intimate trans citizenship while incarcerated in Australia and the United States.

Trans women incarcerated throughout the world have been described as "vulnerable populations" due to significant victimization, mistreatment, lack of gender-affirming care, and human rights violations, which confers greater risk of trauma, self-harm, and suicide compared with the general incarcerated population. Most incarceration settings around the world are segregated by the person's sex characteristics (i.e., male or female) and governed by strong cis and gender normative paradigms. This analysis seeks to better understand and appreciate how the "instructions" and the "authorities" that regulate trans women's corporeal representation, housing options and sense of self-determination implicate and affect their agency and actions in handling intimacies related to their personal life. Drawing upon lived incarcerated experiences of 24 trans women in Australia and the United States, and employing Ken Plummer's notion of intimate citizenship, this analysis explores how trans women navigate choices and ways "to do" gender, identities, bodies, emotions, desires and relationships while incarcerated in men's prisons and governed by cis and gender normative paradigms. This critical analysis contributes to understanding how incarcerated trans women through grit, resilience, and ingenuity still navigate ways to embody, express and enact their intimate citizenship in innovative and unique ways.

A Critical Discourse Analysis of an Australian Incarcerated Trans Woman's Letters of Complaint and Self-Advocacy.

This case study provides a critical discourse analysis of 121 letters of complaint and self-advocacy authored by Natasha Keating, a trans woman incarcerated in two Australian male correctional facilities from 2000 to 2007. During her incarceration, Natasha experienced victimization, misgendering, microaggression, and institutional discrimination. Despite this, Natasha embodied and "fought" against the injustices she experienced, whilst seeking to speak for other trans incarcerated persons also silenced and treated with indifference, contributing to changes in the carceral system. This original case study analyzes the discursive strategies Natasha employed to construct and reclaim an affirming self-identity through a deliberate campaign to effect social change and policy concessions within a system designed to curtail self-determination. Through her empathic and impassioned letter-writing approach, leveraging a military metaphor, this novel analysis showcases the significant implications her activism/agentism and determination had in naming and seeking to dismantle the systems of oppression trans incarcerated women experience.

Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation.

Though preventable in most cases, pressure ulcers continue to pose a major burden to the individual and society, affecting ≤3 million adults annually in the United States alone. Despite increased national attention over the past 20 years, the prevalence of pressure ulcers has largely remained unchanged, while the associated costs of care continue to increase. Dermatologists can play a significant role in pressure ulcer prevention by becoming aware of at-risk populations and implementing suitable preventive strategies. Moreover, dermatologists should be able to recognize early changes that occur before skin breakdown and to properly identify and stage pressure ulcers to prevent delay of appropriate care. The aim of the first article in this continuing medical education series is to discuss the pathophysiology, risk factors, epidemiology, social and economic burdens, and clinical presentation of pressure ulcers.

Pressure ulcers: Prevention and management.

Prevention has been a primary goal of pressure ulcer research. Despite such efforts, pressure ulcers remain common in hospitals and in the community. Moreover, pressure ulcers often become chronic wounds that are difficult to treat and that tend to recur after healing. Especially given these challenges, dermatologists should have the knowledge and skills to implement pressure ulcer prevention strategies and to effectively treat pressure ulcers in their patients. This continuing medical education article focuses on pressure ulcer prevention and management, with an emphasis on the evidence for commonly accepted practices.

Experiences of transgender prisoners and their knowledge, attitudes, and practices regarding sexual behaviors and HIV/STIs: A systematic review.

Background: Despite transgender people being more visible in prison systems, research suggests they are at higher risk of experiencing sexual violence compared to other prisoners. Research also suggests that transgender prisoners experience harassment, and physical and sexual assault by fellow prisoners, and prison officers who lack transgender-specific health knowledge. There exist no systematic reviews on the experiences of transgender people in prisons. This review aims to fill this research gap. The following question developed in consultation with transgender, sexual health/HIV and corrective services stakeholders has guided the systematic review: What are transgender and gender-diverse prisoners' experiences in various prison settings and what are their knowledge, attitudes and practices regarding sexual behaviors and HIV/STIs? Methods: The review followed the PRISMA guidelines and searches were conducted in four databases for the period of January 2007 to August 2017. Studies were assessed against predetermined inclusion and exclusion criteria. Included studies were peer-reviewed, written in English with online full-text availability and reported data on transgender and gender-diverse prisoner experiences relevant to the research question. Results: Eleven studies (nine qualitative, one quantitative, one mixed-methods; nine in USA, two in Australia) met the criteria for review. Four studies were of high quality, six were of good/acceptable quality, and one study was of modest quality. Transgender and gender-diverse prisoners reported a range of challenges which included sexual assault, discrimination, stigma, harassment, and mistreatment. Information on their sexual health and HIV/STIs knowledge, attitudes, practices is in short supply. Also, their lack of access to gender-affirming, sexual health/STIs and mental health services is commonplace. Conclusions: The experiences of transgender prisoners as reported in this review are almost uniformly more difficult than other prisoners. Their "otherness" is used as a weapon against them by fellow prisoners through intimidation and violence (including sexual) and by prison officers through neglect and ignorance.

Exploring HIV risks, testing and prevention among sub-Saharan African community members in Australia.

BACKGROUND: Significant health disparities persist regarding new and late Human Immunodeficiency Virus (HIV) diagnoses among sub-Saharan African (SSA) communities in Australia. Personal/cultural beliefs and practices influence HIV (risk, prevention, testing) within Australia and during visits to home countries. METHOD: A community forum was conducted involving 23 male and female adult African community workers, members and leaders, and health workers; facilitated by cultural workers and an experienced clinician/researcher. The forum comprised small/large group discussions regarding HIV risk/prevention (responses transcribed verbatim; utilising thematic analysis). RESULTS: Stigma, denial, social norms, tradition and culture permeated perceptions/beliefs regarding HIV testing, prevention and transmission among African Australians, particularly regarding return travel to home countries. CONCLUSIONS: International travel as a risk factor for HIV acquisition requires further examination, as does the role of the doctor in HIV testing and Pre-exposure Prophylaxis (PrEP). Further assessment of PrEP as an appropriate/feasible intervention is needed, with careful attention regarding negative community perceptions and potential impacts.

Lymphedema: Pathophysiology and clinical manifestations.

Lymphedema is a localized form of tissue swelling resulting from excessive retention of lymphatic fluid in the interstitial compartment and caused by impaired lymphatic drainage. Lymphedema is classified as primary or secondary. Primary lymphedema is caused by developmental lymphatic vascular anomalies. Secondary lymphedema is acquired and arises as a result of an underlying systemic disease, trauma, or surgery. We performed PubMed and Google Scholar searches of the English-language literature (1966-2017) using the terms lymphedema, cancer-related lymphedema, and lymphatic complications. Relevant publications were manually reviewed for additional resources. This progressive chronic disease has serious implications on patients' quality of life. It is often misdiagnosed because it mimics other conditions of extremity swelling. There is no definitive cure for lymphedema. However, with proper diagnosis and management, its progression and potential complications may be limited.

Lymphedema: Diagnostic workup and management.

Lymphedema is a localized form of tissue swelling resulting from excessive retention of lymphatic fluid in the interstitial compartment. It is caused by impaired lymphatic drainage. Lymphedema is a chronic progressive disease with serious physical and psychosocial implications. It can be challenging to diagnose, especially in obese patients and in those with coexisting venous disease. We performed PubMed and Google Scholar searches of the English-language literature (1966-2017) using the terms lymphedema, lymphedema management, and lymphatic complications. Relevant publications were manually reviewed for additional resources. There are currently no standard guidelines for the diagnosis of lymphedema. There is no cure yet for lymphedema, and the objective for management is to limit disease progression and prevent complications.

Wound healing and treating wounds: Differential diagnosis and evaluation of chronic wounds.

Wounds are an excellent example of how the field of dermatology represents a cross-section of many medical disciplines. For instance, wounds may be caused by trauma, vascular insufficiency, and underlying medical conditions, such as diabetes, hypertension, and rheumatologic and inflammatory disease. This continuing medical education article provides an overview of wound healing and the pathophysiology of chronic wounds and reviews the broad differential diagnosis of chronic wounds. It also describes the initial steps necessary in evaluating a chronic wound and determining its underlying etiology.

Wound healing and treating wounds: Chronic wound care and management.

In the United States, chronic ulcers--including decubitus, vascular, inflammatory, and rheumatologic subtypes--affect >6 million people, with increasing numbers anticipated in our growing elderly and diabetic populations. These wounds cause significant morbidity and mortality and lead to significant medical costs. Preventative and treatment measures include disease-specific approaches and the use of moisture retentive dressings and adjunctive topical therapies to promote healing. In this article, we discuss recent advances in wound care technology and current management guidelines for the treatment of wounds and ulcers.

Coagulation disorders and their cutaneous presentations: Pathophysiology.

Hypercoagulable states are inherited or acquired predispositions to venous or arterial thromboses that are best understood in the context of the coagulation cascade. Dermatologists can play a critical role in diagnosing and treating patients with hypercoagulable states because cutaneous symptoms may be a presenting manifestation, thereby reducing morbidity and mortality related to these conditions. This review focuses on the epidemiology and pathophysiology of hypercoagulable states, while the accompanying article iterates the basic clinical features, diagnostic testing, and management of patients who have these conditions.

Coagulation disorders and their cutaneous presentations: Diagnostic work-up and treatment.

Both inherited and acquired hypercoagulable states can present with nonspecific clinical manifestations, such as petechiae, purpura, livedo reticularis, and ulcerations. A good history and physical examination are crucial to diagnoses of these conditions. Inherited conditions tend to present either in neonatal period or later in life, while acquired conditions typically occur later in life. Diagnostic studies are performed to identify the coagulation cascade deficiency or defect. Treatment primarily hinges on anticoagulation and wound care. In this article, we provide an in-depth analysis of the clinical manifestations, diagnostic considerations, and management options of patients in hypercoagulable states.

What's new: Management of venous leg ulcers: Approach to venous leg ulcers.

Leg ulcerations are a common problem, with an estimated prevalence of 1% to 2% in the adult population. Venous leg ulcers are primarily treated in outpatient settings and often are managed by dermatologists. Recent advances in the diagnosis and treatment of leg ulcers combined with available evidence-based data will provide an update on this topic. A systematized approach and the judicious use of expensive advanced therapeutics are critical. Specialized arterial and venous studies are most commonly noninvasive. The ankle brachial pressure index can be performed with a handheld Doppler unit at the bedside by most clinicians. The vascular laboratory results and duplex Doppler findings are used to identify segmental defects and potential operative candidates. Studies of the venous system can also predict a subset of patients who may benefit from surgery. Successful leg ulcer management requires an interdisciplinary team to make the correct diagnosis, assess the vascular supply, and identify other modifiable factors to optimize healing. The aim of this continuing medical education article is to provide an update on the management of venous leg ulcers. Part I is focused on the approach to venous ulcer diagnostic testing.